Motor Control and Motor Learning - Module 5

Emily demonstrates poor postural control which impacts her ability to maintain upright postures during various routines of the educational setting. She may lean on her peers when sitting on the carpet at circle time or when standing in line. She may lean or rest her head in her left hand during fine motor tasks which limits her ability to use two hands in a coordinated fashion, thereby decreasing her control and output for tasks such as cutting, coloring, prewriting, and ADL’s. Her decreased postural control also impacts her ability to participate in gross motor activities in terms of her ability to initiate her participation and to maintain her participation for the same duration as her typical peers.

Emily is provided with adaptations to increase her support when involved in more challenging tasks or interactions (fine motor, interactions, etc) so that she is better able to participate and not have to worry about her body in space. When in the classroom, there are times when she is also encouraged to assume various positions during play (standing to color at an easel, tall knell to play with toys on a bench or shelf, prone propped to look at a book, etc…) to work on increasing postural control. When she is playing in positions that are more challenging, we make sure that the task she is participating in is a mastered skill or not too challenging, so she can “attend” to her body position. Emily also has opportunities to work one on one or with small groups in a gross motor/therapy room to utilize various therapeutic equipment (swings, trampolines, therapy balls, crash pads, etc…). Emily is motivated to engage in activities utilizing the various equipment but can be hesitant when initially brought into the motor room (therapy room). She often approaches a task with initial frustration as she appears to be overwhelmed by the “looks” of the activity. With guidance, we discuss the activity and how we could approach the activity; she tends to take her time which is interesting after reading about motor control and planning. Again, making sense as to the why.

Some treatment strategies that I will be sure to include will be to set up the activity to ensure motivation. She really enjoys various swings but can be hesitant initially to interact with novel ones. I might have the novel swing hanging in the therapy room for a few sessions hoping that she will inquire and initiate use. If not, I will provide some information and a few ideas (verbally and or demonstration) to entice participation. I will be sure to allow her ample time to initiate and engage in the swing, making sure that I don’t “jump in” too early to “help”. I will want to facilitate a positive initial experience, giving her the time to adjust and respond (reactively) and over time as she demonstrates more comfort, increase the response time and look for more automatic and anticipatory participation.

Week 4 - Cognition/Action/Perception/Modulation

Emily's most recent evaluation was completed by a team consisting of a psychologist, special education teacher, speech and language pathologist, and occupational therapist. Various testing procedures were completed in the different disciplines that occurred in a testing environment as well as multiple observations that occurred within more natural settings. As an aside, the individual testing information provided very helpful and informative information, however, it was the observation pieces that looked at how her strengths and needs as identified in testing impacted her functionally within the context of her environment. For example, when utilizing the PDMS -2 (fine/perceptual motor testing), she did not demonstrate a 25% delay. However, when she was observed in the classroom setting, she demonstrated significant difficulties participating in activities that involved these skills. She utilized less efficient grasps, approaches to tasks and decreased abilities to use two hands in a coordinated fashion. Taking into account the information from the sensory profiles that were completed as well as the observational information, it became clear that Emily's sensory processing difficulties in the areas of auditory, tactile, visual, proprioceptive and movement processing were impacting her ability to utilize her discreet skills during meaningful activities within her classroom setting.

Identified strengths and needs and treatment strategies:
Preacademic- knows shapes, colors, letters and numbers with adequate academic concepts reported.

Receptive/Expressive Language- follows 3 step related and unrelated directions, correct use of grammar, articulation age appropriate, age appropriate expressive and receptive skills.

Pragmatic Language- inconsistent abilities to make her wants and needs known, inconsistent abilities initiating appropriately (invades others personal space, inappropriate touch of others), needs facilitation for topic maintenance (her choice and another's choice), decreased abilities to process her own emotions and those of others. Tx strategies to include - face processing activities/games (understanding/reading facial expressions and emotions, self regulation, social initiations, etc...), - role playing to practice various strategies, -social stories, -referencing activities/games (add in "where am I looking" or "look over there and what do you see" games to work on her ability to follow eye gaze -thank you Amy)

Fine/Perceptual Motor Development- decreased postural control impacting her ability to maintain upright static positions while completing fine motor tasks, immature grasp pattern on writing implement, inconsistent but improving two hand usage, motivated to complete puzzles and prewriting activities but is resistant to adult facilitation for correct participation. Tx strategies to include – activities to continue to develop postural control and shoulder stability to increased "stability" for increased "mobility" of hand skills, - hand skill activities to continue to develop strength and control for grasp patterns, - activities to develop more automatic two hand usage

Gross Motor Development- w-sits but will correct when prompted, able to navigate within her environment and participate in motor games and activities, able to coordinate both sides of her body to engage in hopping, galloping and running activities but becomes overly excitable and difficult to calm after. Tx strategies to include – monitor performance in gross motor activities to ensure ability to modulate and maintain appropriate interactions with her peers providing teaching strategies for awareness of body cues and how to go about achieving regulation

Play- preferred areas of play within the classroom needing facilitation to expand her play, shares materials with peers, resistant to transition from preferred to nonpreferred play areas. Tx strategies to include – use of timer to prepare for transitions, - use of visuals, - working on motor planning components to address the possibility of decreased ability for planning of what to do next as is needed to transition to even another preferred activity.

Self-Help- able to care for personal needs and belongings, independent with bathroom and mealtime routines, no reports listed at this time regarding sleep habits or GI issues.

Social-Emotional- attention for preferred tasks is good, decreased frustration tolerance and inconsistent requests for help requiring very quick intervetion from an adult to try to avoid "melt downs" or tantrums (running away from the area, crawling under furniture, screaming, falling onto the floor). Tantrums may occur when frustrated, during transitions, when she does not get "what she wants". Likes adult attention and often engages in attention getting behaviors that are being inadvertantly reinforced in the classroom. Emotions can range from high (uncontrollable giggling) to low (screaming and yelling) within short periods of time. Tx strategies to include – monitoring level of environmental complexity, incorporating environmental strategies to make the right fit for Emily – sensory modulation utilizing strategies for self- regulation (ability to remain organized), mutual regulation (ability to seek or accept assistance from another for support to maintain emotional regulation) and recovery from extreme dysregulation (ability to “recover” from emotional dysregulation or “attentional shutdown” through strategies of self or mutual regulation.)

Sensory Motor Development- postural control deficits impacting functional performance during seated tasks (circle time - attention, table top activities) and peer interactions - may lean on peers. Demonstrating difficulties with self regulation. Sensory processing difficulties in proprioceptive, vestibular, visual, auditory and touch. Tx strategies to include - utilizing the stategies of self regulation (thermometer, engine speed) when in various environments, - activities for increased postural control, - involvement in activities and implementation of strategies to incorporate propriocepive, vestibular and touch inputs.

Coordination with other professionals working with Emily as well as her family for consistency and carryover of techniques and strategies into various environments and with various people.

Environmental Complexity

Emily’s ability to manage environmental complexity is certainly a challenge. As mentioned in an earlier post, her ability to participate in the classroom improves significantly when there are fewer children present. The overall sensory qualities of the environment greatly impact her ability to maintain the just right arousal level for optimal attention, motivation, and social interactions. When more children are present in the classroom, the unpredictability of the environment increases as well as an increased level of sensory input which as we have learned increases anxiety and decreases attention. It has been interesting to really think about this child in relation to the specific content areas that we are covering in class.

This is a child who was performing fairly well in a specialized Early Intervention classroom that had smaller numbers of kids and high predictability by design (visuals schedules, built in sensory activities, teacher facilitation for social interactions and play). Because of the strengths demonstrated in this setting, she was transitioned to a setting with much more environmental complexity that was probably not considered and planned for adequately enough to facilitate a successful transition. At this point I feel as if we are back pedaling and adding the supports; if the supports were in place to begin with and then faded systematically, her transition would have been more successful. Many of the strategies that I discussed in the earlier post will also help to support thte challenges this student faces with environmental complexities.

I try to find positives in every situation. Realizing that Emily is transitioning into kindergarten in the fall, I feel this situation has brought to light important aspects that the team will be able to share with the district in terms of supports and strategies that will help Emily deal with the new environmental complexities that she will encounter in kindergarten.

Communication and Behavorial Strengths and Needs

Emily demonstrates an understanding of basic concepts and vocabulary and can follow 3 step related and unrelated directions when interested in the task or directive. She has more difficulty with abstract concepts. Expressively, she is able to use correct grammatical forms and vocabulary and can formulate complete sentences to relate information. Emily’s pragmatic language skills are an area of weakness. She inconsistently expresses her feelings in appropriate ways, often invades the space of others when talking and/or touches people inappropriately (going up to someone and hugging them without warning). She requires facilitation for topic maintenance (her choice and another’s choice) and has difficulty responding to emotions of others and responding to social cues.

Emily demonstrates adequate attention for preferred tasks. She inconsistently asks for help and becomes easily frustrated. Emily will engage in avoidance behaviors, and attention seeking behaviors all of which are currently being inadvertently reinforced by the Head Start teachers in an attempt to avoid episodes of Emily throwing herself onto the ground, running away from the teacher, and crying during transitions from preferred to non preferred tasks. Emily’s overall performance in the classroom improves when there are fewer children present. Various strategies that have been incorporated into her routine and those that are being considered:
1. The use of a visual schedule for the general classroom routine. The visual schedule is being utilized inconsistently depending on the staff serving the classroom on a given day. Emily requires assistance to know what to do during more unstructured routines including “play time”. The utilization of a play schedule is being considered for use to help to Emily organize and plan this specific unstructured time.
2. She has been assigned “jobs” during the classroom in an effort to give Emily the adult attention she seeks but for positive behaviors/participation. Unfortunately, most of the interactions between the Head Start staff and Emily have occurred when Emily is displaying undesired behaviors.
3. A behavior modification chart has been introduced to the classroom where children hang their names on the Yellow poster when displaying the identified rules and “good behavior”. When the identified negative behaviors or breaking of class rules occurs, the child places his name on the Red poster. The intent is for the child to engage in a positive behavior or correct their behavior and quickly move his name back to yellow. Emily has been responding to this chart and technique when utilized consistently by the staff.
4. A timer is being utilized to assist Emily with her ability to transition.
Preferential seating has been considered for Emily so that she is in closer proximity to the teacher.
5. There have been discussions of utilizing some sort of token system but this has not yet been implemented. I will be pushing for this next week!!!
6. Concepts of self regulation are going to be introduced both within he individual OT sessions with carry over of techniques and strategies into the classroom. Concepts from the Alert Program will be utilized. Pictures and sequences will be used from the Stick Kids computer software (great program) as well as from the Super Duper fun decks (also a nice resource)

8. Implementation of social stories to assist with the social communication aspect will be something to investigate as well.
7. Due to inconsistent follow through by the Head Start Staff, Early Intervention staff have increased their support within the classroom to provide consistency for Emily within her natural environment and to model the techniques for the Head Start staff.